Perioral Dermatitis Questionnaire

Perioral dermatitis is a facial rash that tends to occur around the mouth. Most often it is red and slightly scaly or bumpy. Any itching or burning is mild. It may spread up around the nose, and occasionally the eyes while avoiding the skin adjacent to the lips. The test on all subjects will involve swabbing the perioral area. Participants are asked to forego using cosmetic products for three days (cleansing with a mild soap or cleanser is allowed).

Thank you for volunteering. The project team leader will be in touch with you to schedule an in-person interview. All information will be kept private and confidential.

Name
Age
Email
Phone
Please check which group you are volunteering to participate in -
If you checked Group B or C, have you been diagnosed by a dermatologist?
If you checked Group B or C, how long have you had Perioral Dermatitis?
Are you willing to forego using facial care products for three days prior to testing?
Current / previous skin care regimen
Current medications
Any known internal imbalances or illnesses